Disorders of sodium balance in patients with hypothalamic-pituitary lesions in traumatic brain injury

Background. Traumatic brain injury (TBI) still remains the leading cause of death in people of working age. In Ukraine, the frequency of TBI varies from 2.3 to 6 cases (average of 4–4.2) per 1,000 population annually depending on the regions. Patients with primary damage to the brain and hypothalamic-pituitary system are at risk of developing cerebral edema due to the water-electrolyte imbalance and, accordingly, osmolar imbalance between cellular and extracellular spaces. Water-electrolyte imbalance as a result of damage to the hypothalamic-pituitary system in traumatic brain injury is not described enough in the literature. The functioning of the central and peripheral links of the endocrine system depending on the location, nature and severity of injury is examined not enough. The question of diagnostic and prognostic values of various indicators of volume status in patients with trauma is also underinvestigated. The purpose of this study was to examine the types of disorders of sodium balance in patients with isolated TBI and hypothalamic-pituitary lesions; to clarify the influence of sodium imbalance type on mortality in patients with TBI and hypothalamic-pituitary lesions. Material and methods. We examined 74 patients (men/women = 60/14) with focal cerebral contusion and lesions of the hypothalamic region. Forty-seven of them were diagnosed with hypovolemia combined with hyponatremia. Hypernatremia with hypervolemia was found in 15 patients. Intracranial pressure monitoring was performed using a multifunction monitor (BSM-3562, Japan, 2018, Nihon Kohden Corporation) with a line for invasive pressure measurement. Continuous non-invasive measurement of organ tissue oxygenation (rSO2) was carried out using Somanetics Invos Oximeter Cerebral/Somatic monitor (Covidien, Mansfield, MA, USA, 2020). Plasma electrolytes were evaluated in all patients. Conclusions. Patients with TBI and hypothalamic-pituitary lesion have different types of water-sodium imbalance, which demand the differentiated approach to their treatment. Given the small number of observations, we do not dare to link the type of sodium imbalance with lethality in patients with brain trauma and hypothalamic-pituitary lesions. We consider this requires further researches.

Visual disturbance as primary symptom of pituitary apoplexy in pregnancy

Pituitary apoplexy in pregnancy is a potentially fatal condition caused by acute ischaemic infarction or haemorrhage of pre-existing pituitary adenoma or within a physiologically enlarged pituitary gland. It has a wide spectrum of clinical presentations ranging from a mild headache to sudden collapsed. Here, we report a life-threatening case of pituitary apoplexy in a non-functioning pituitary macroadenoma occurring during pregnancy that presented with bilateral blurring of vision. Visual field showed bitemporal superior quadrantanopia. Urgent non-contrast brain MRI revealed an acute expansion of a hemorrhagic pituitary lesion complicated with local compression to the optic chiasm. The patient underwent an uneventful right supraorbital craniotomy and excision of the tumour under general anaesthesia with no foetal loss. The repeated visual field at 2 weeks after surgery showed recovering visual field defect. Hence, early neurosurgical intervention is advisable to prevent mortality and morbidity due to permanent visual field loss.

Case of an atypical pituitary abscess

A pituitary abscess is a rare intrasellar infection. Correct identification can be challenging preoperatively given its non-specific symptoms and imaging findings. We report a case of a young woman presenting with secondary amenorrhea, visual field deficits and a 2.6 cm pituitary lesion diagnosed to be a craniopharyngioma. A concomitant unexpected pituitary abscess was diagnosed intraoperatively without associated meningeal symptoms.

Immunoglobulin G4 hypophysitis in a 63-year-old woman with no autoimmune history: a case report

Background Immunoglobulin-G4-related hypophysitis is a rare inflammatory disease that can present as a tumefactive pituitary lesion mimicking hypophyseal neoplasms such as pituitary adenoma or craniopharyngioma. The literature on this entity is sparse, with fewer than 100 cases reported across 19 publications; a recent review found only 24 cases published from 2007 to 2018. Previous reports have described demographic differences, with immunoglobulin-G4-related hypophysitis in females tending to present in the second and third decades in association with other autoimmune disease, while males tend to present in the fifth and sixth decades of life without an autoimmune history. Case presentation In contrast to the reported demographic trends, here we describe a unique case of immunoglobulin-G4-related hypophysitis in a 63-year-old white female with no history of autoimmune disease who presented with a rapidly enlarging sellar and hypothalamic mass causing headaches and cranial nerve palsies, prompting biopsy for diagnosis. The patient experienced rapid response to treatment with high-dose steroids and rituximab. Conclusion The case contributes to the growing clinicopathologic description of immunoglobulin-G4-related hypophysitis and illustrates that this diagnosis should be a consideration even outside the conventional demographic setting.

1351 Primary Pituitary Abscess Presenting as An Isolated Bitemporal Hemianopia

Pituitary abscesses are rare yet life-threatening entities. Most common presenting features are headache, hypopituitarism, and visual changes. Majority of patients are found to have a predisposing risk factor, such as a pre-existing pituitary lesion, recent pituitary surgery or irradiation, or a primary source of infection. We present the case of a 53-year-old male with a spontaneous pituitary abscess, who presented with an isolated bitemporal hemianopia, but was otherwise asymptomatic with no known risk factors. Magnetic resonance imaging showed a sellar and suprasellar mass, thought to be a pituitary macroadenoma. He underwent endoscopic transsphenoidal adenectomy and cystic fluid was seen intraoperatively. Microbiology analysis showed Staphylococcus Aureus, and a course of intravenous ceftriaxone was commenced. Histopathology reported no evidence of adenoma and impression was of a pituitary abscess. Following transsphenoidal resection and commencement of antibiotic therapy, the bitemporal hemianopia resolved. We therefore report a rare case of primary pituitary abscess and emphasise the importance of including this condition as a differential diagnosis in any patient with a visual deficit or new pituitary lesion.

426 An Evaluation of The Service of Endoscopic Trans-Sphenoidal Surgery for Excision of Pituitary Lesion During The SARS-Cov-19 Pandemic

Introduction Since the start of SARS-CoV-2 pandemic many branches of medicine and surgery have undergone changes shifting the focus to prepare for an increase of COVID-19 related admissions. Halting all pituitary surgery services was not feasible particularly if patients present with acute or progressive visual loss due to the mass effect of the pituitary lesion, pituitary apoplexy, or lesions with aggressive features. Method An 11-point telephone questionnaire was used to evaluate the service provided between March and September 2020. On a 1-10 scale, patients scored their feelings about remote clinics, the support offered, the clarity of explanations, quality of interaction with their surgeon, and an overall assessment of remote clinics. Results 20 of the 21 patients who underwent transsphenoidal pituitary lesion resection between the 02/03/2020 and 14/09/2020 participated in the survey. They unanimously felt the introduction of remote consultations was necessary and felt safer. Their surgeon’s communication skills helped their experience the most. It allowed for easier attendances as they did not rely on family or long travelling times. Drawbacks involved the lack of face-to-face interaction particularly pre-operatively, as patients felt they missed the human factor, seeing their scans, and meeting their surgeon in person. Conclusions The pandemic has affected people from a biopsychosocial perspective leaving long-lasting effects on the economy and healthcare systems of the world. This service evaluation highlights a positive outcome in terms of patient experience. Moving forward, incorporating remote services as an option for follow-up cases would be welcomed by most patients in the survey.

Autoimmune Hypophysitis with Late Renal Involvement: A Case Report

We report a case of a 50-year-old male admitted to the Endocrinology Unit because of persistent headaches, nausea, feeling tired, sudden weight loss, cold intolerance, decreased appetite, and lack of sex interest. Diagnostic workup showed a 6-millimeter pituitary tumor without signs of compression, and a condition of progressive panhypopituitarism. After 12 months of hormone replacement therapy, the patient was hospitalized because of sudden weight gain, periorbital-peripheral edema, severe dyslipidemia, hypertension, and proteinuria. Corticosteroid therapy was shifted from oral to continuous intravenous infusion, and once the diagnosis of “immune complex-mediated glomerulonephritis with mesangial deposits suggestive for membranoproliferative glomerulonephritis type IIIIgG4-positive” was made, the immunosuppressant mycophenolate (1500 mg/day) was started. After a 6-month follow-up, the complete resolution of renal symptoms was accompanied by the disappearance of a pituitary lesion and the patient was back to prior hormone replacement therapy. Autoimmune hypophysitis (AH) is a rare autoimmune inflammatory disease of the pituitary gland that can impair hormone secretion and function. IgG4-hypophysitis is rare and is usually associated with other IgG4-related diseases. Herein, we describe a rare case of AH associated with late renal disease, and without any other organ involvement.

Symptomatic Chiari type 1 malformation associated with acromegaly: A case report

Background: Here, we report a patient who presented with both symptomatic acromegaly and symptomatic Chiari I malformation (CM1) with a C2-T5 syrinx. Case Description: A 63-year-old female presented with bilateral arm dysesthesias and back pain. For approximately the past 30 years, she had chronic signs of acromegaly (i.e. an enlarged forehead, jaw, and nose, and enlarged hands and feet). When the cervical magnetic resonance showed a CM1 (tonsillar herniation) with C2-T5 syringomyelia, she underwent foramen magnum decompression and C1 posterior arch resection. Postoperatively, she was asymptomatic. The added finding of a growth hormone (GH)-producing pituitary lesion was treated medically with endocrine therapy, as she had incidentally required surgery/chemotherapy for a newly diagnosed colon cancer. Conclusion: Symptomatic CM1, syrinx, and acromegaly may occur together. Appropriately treatment may include a suboccipital decompression, and C1 arch resection surgery, followed by either surgical or medical treatment for the GH-producing pituitary adenoma.

Pituitary Hyperplasia Secondary to Primary Hypothyroidism Mimicking a Macroadenoma With Optical Chiasm Compression

Background: A long term untreated primary hypothyroidism can stimulate thyrotropes proliferation, leading to pituitary hyperplasia. This condition is known as pituitary hyperplasia secondary to primary hypothyroidism (PHPH). It is a rare condition that mimics pituitary adenoma and can achieve large proportions with optic chiasm compression. A misdiagnosis may be catastrophic, and a pituitary resection wrongly performed. Clinical Case: A 25-year-old woman with a medical history of delayed neuro psychomotor development and epilepsy due to congenital CNS malformation had a Brain MRI performed for epilepsy follow-up three years earlier. At that time, neuroimaging had shown a pituitary enlargement, and laboratory data were diagnostic of severe primary hypothyroidism with TSH of 290.6 uUI/mL (normal range 0.4 to 4.5 uUI/mL) and T4L <0.23 ng/dL (normal range: 0.9 to 1.8 ng/dL). She then had received a 75 mcg levothyroxine prescription. However, the patient missed medical follow-up and returned three years later, when sella turcica MRI showed a 0.9x1.0x1,4 cm pituitary lesion, consistent with a macroadenoma with suprasellar extent near the optic chiasm. Because of the cognitive impairment, the patient was not able to complete the visual field test. Neurology service referred the patient to endocrinology evaluation for surgical treatment. Hypothyroidism was still uncontrolled with TSH 157.1 uUI/mL and T4L 0.28 ng/dL. We had adjusted the levothyroxine dose to 125 mcg and advised adherence. Subsequent thyroid function tests had shown TSH 6.91 uUI/mL and T4L 1.15 ng/dL. After thyroid function stabilization, the patient performed a new sella turcica MRI, which had not evidenced pituitary lesion. Pituitary hyperplasia secondary to primary hypothyroidism was her final diagnosis. Conclusion: This case report illustrates the importance of the correct diagnosis and treatment of PHPH. Levothyroxine replacement, with TSH normalization, reverses the gland hyperplasia within 2 to 4 months. References: 1. Cao J, Lei T, Chen F, Zhang C, Ma C, Huang H. Primary hypothyroidism in a child leads to pituitary hyperplasia: A case report and literature review. Medicine (Baltimore). 2018 Oct;97(42):e12703.2. Shivaprasad KS, Siddardha K. Pituitary Hyperplasia from Primary Hypothyroidism. N Engl J Med. 2019 Feb 21;380(8):e9.

INCIDENTAL FINDING OF PITUITARY MACROADENOMA IN A PATIENT WITH CHRONIC SUBDURAL HAEMATOMA: A CASE REPORT

Background: With the advent of modern radiologic imaging there is increase in the detection of pituitary lesions in imaging done for others non-related lesion. The aim of this review is to report our first case of pituitary incidentaloma in a patient who was evaluated for chronic subdural haematoma Case Presentation: A 65-year-old known hypertensive presented initially to the internal physicians with severe headache, change in sensorium and right sided weakness. He has had history of a fall 6 weeks prior to presentation. His Glasgow coma scale score was 14/15 (E4V4M6). The power on his right upper and lower limbs was 3/5 and on the left limbs was 5/5. He had global exaggerated reflexes and hypertonia. Computerized Tomographic (CT) Scan of the brain done showed massive left subdural haematoma and 14 by 12 by 15 sellar mass. (Figure 1) Pituitary hormonal assay showed decrease in cortisol and other pituitary hormones with slight increase in prolactin. He subsequently had unilateral double burr hole and drainage. He did very well and was discharged 2 days after surgery. At his first follow up visit he was offered the option for further evaluation and treatment of the pituitary lesion but he declined due to financial constraints. Conclusion: Incidental finding of pituitary tumour is a reality in our setting. A lot need to be done to make modern radiological imaging readily available and affordable to increase yield.